State Absentee Ballot Request Form, North Carolina Page 2
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1
2TO:
Alamance County Board of Elections
State Absentee Ballot Request Form
115 S. Maple Street
Graham, NC 27253
North Carolina
PHONE: 1-336-570-6755
FAX: 336-570-6757
Alamance.sboe @ncsbe.gov
FRAUDULENTLY OR FALSELY COMPLETING THIS FORM IS A CLASS I FELONY UNDER CHAPTER 163 OF THE NC GENERAL STATUTES.
I am requesting an absentee ballot for the:
on
.
Election Type (Primary, General, Municipal, Special, etc.)
Election Date
Voter Information
Last Name
First Name
Middle Name
Suffix
Date of Birth
Home Address (NC Residential Address.)
Mailing Address (If different than home address.)
City
State
Zip Code
City
State
Zip Code
County of Residence
Previous Name (if applicable)
Have you lived at this address for more than 30 days?
Yes
No
_____ /_____ / _____
If “No,” indicate the date of your move:
You must provide at least one identification number below. (or see instructions)
Voter Registration No.
Phone (optional)
Email (optional)
NC License or ID Number
SSN
X X X - X X -
Absentee Voting Information
Absentee Mailing Address (Where should the ballot be mailed?)
City
State
Zip Code
If voter is registered as Unaffiliated and requesting a ballot for a partisan primary, choose a primary ballot preference.
Democratic
Republican
Libertarian
Non-partisan
If voter is a patient in a hospital, clinic, nursing home or rest home, please indicate whether you will need assistance in marking your ballot.
Yes
No
If “Yes,” what is the name and address of the hospital or facility:
If requesting an absentee ballot on behalf of a near relative, list your name, address, contact information and relationship to the voter:
Requestor’s Name
spouse
brother /sister
parent
grandparent
stepparent
child
grandchild
stepchild
mother-in-law
father-in-law
son-in-law
daughter-in-law
legal guardian
(First)
(Middle)
(Last)
(Suffix)
Requestor’s Address
Name of Corporation (If appointed legal guardian)
City
State
Zip Code
Requestor’s Phone
Requestor’s Email
For Military/Overseas Citizens Only
(may only be signed by the voter; may not be signed by a near relative/guardian)
Select one of the options below to qualify as a military or overseas voter:
Member of the Uniformed Services or Merchant Marine on active duty and currently absent from county of residence or an eligible spouse/dependent.
U.S. citizen residing outside the U.S. temporarily or indefinitely
Current Address (Address where you are currently stationed or living overseas.)
Transmit my ballot by:
Mail
Fax
Email
(Military/Overseas Voters Only)
Fax Number or Email Address
Signature of Voter
Signature of Near Relative/Legal Guardian
(voter only)
(if applicable)
X
X
Date
Date
Visit to check your voter registration or absentee voting status.
V2013.11
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